Columbia Healthcare Center

Based on interview, and record review, the facility failed to follow Physicians Orders. A resident with a pressure ulcer did not receive antibiotics and treatment as ordered for 1 of 4 residents reviewed for quality of care. (Resident C)Finding includes:On 11/12/25 at 11:40 A.M., Resident C's clinical record was reviewed.

Diagnoses included, but were not limited to, type 2 diabetes mellitus and gout.The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 9/29/25, indicated Resident C had moderate cognitive impairment, 1 unstageable pressure ulcer, and was not on a turning and repositioning program.

Resident C required substantial to maximal assistance of staff (staff performs more than half the effort) for transfers and toileting.Care plans included, but were not limited to, the following:Impaired mobility related to right foot osteomyelitis with an intervention to turn and reposition Resident C every 2 hours, dated 10/21/25.The resident had a right heel infection with an intervention to administer antibiotics as ordered by the physician, dated 10/16/25.Physicians' Orders included, but were not limited to, the following:Clindamycin (antibiotic) 300 milligrams (mg) oral every 6 hours for wounds started on 8/27/25 and discontinued on 9/1/25.Resident C's medication administration record (MAR) lacked documentation that the dose on 9/1/25 at 4:00 A.M. was administered.Right lateral heel: cleanse with wound cleanser, pat dry, apply skin prep to peri-wound, apply medi-honey to wound bed, then calcium alginate, cover with foam dressing.

Change every day and as needed if soiled or dislodged.

Started on 9/26/25 and discontinued on 10/1/25.Resident C's clinical record and treatment administration record (TAR) lacked documentation that the wound treatment was completed on 9/26/25 from 6:00 A.M. to 6:00 P.M.Cephalexin (antibiotic) 500 mg oral every 8 hours started on 10/6/25 and discontinued on 10/13/25.Resident C's MAR lacked documentation that cephalexin was administered on 10/10/25 at 8:00 P.M. and on 10/11/25 at 12:00 P.M.Right lateral heel: cleanse with wound cleanser, pat dry, apply gauze with wound cleanser to wound bed, cover with an abdominal pad, and wrap with kerlix twice a day, started on 10/15/25.Resident C's clinical record and TAR indicate the treatment was not completed on 10/16/25 and 10/18/25 from 6:00 P.M. through 6:00 A.M. due to the resident sleeping, 10/21/25 from 6:00 P.M. through 6:00 A.M. due to the resident's condition, and 10/21/25 due to the resident was unavailable.

During an interview on 11/13/25 at 11:28 A.M., Certified Nurse Aide (CNA) 3 indicated Resident C was not a resident who needed to be turned and repositioned every 2 hours. At that time, CNA 3 verified on the CNA assignment form that Resident C was not listed as a resident who needed to be turned and repositioned every 2 hours.During an interview on 11/13/25 at 1:25 P.M., the DON indicated Resident C was supposed to be turned and repositioned every 2 hours.

The treatments should have been completed as ordered, and the MAR and TAR should not have been left blank.

She further indicated that if Resident C was asleep, staff should have attempted to wake the resident.On 11/13/25 at 1:19 P.M., the Assistant Administrator indicated the facility did not have a policy related to following Physician's Orders, but it would be their policy to follow orders.This citation was related to intake 2657654.3.1-35(g)(1)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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